Archived: Elizabeth House

Updated 12 April 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was an unannounced comprehensive inspection which took place on 29 February 2016. The inspection was undertaken by one adult social care inspector.

Prior to our inspection we looked at information we received via the Care Quality Commission ‘share your experience’ forms and notifications we had received about the service. A notification is information about important events which the provider is required to send us by law. We contacted the local authority safeguarding, commissioning and quality team and Bury Health watch. They raised no concerns about the service.

During our inspection we spoke with four people who used the service, two relatives, a district nurse and a community arts teacher. We also spoke with the registered manager, deputy manager, homes co-ordinator, three care workers and the cook. The day after our inspection we spoke with two relatives by telephone to ask their opinion of the service

As some people were not able to tell us about their experiences, we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us.

We carried out observations in public areas of the service. We looked at three care records and twelve medication records. We also looked at a range of records relating to how the service was managed including; three staff personnel files, staff training records, duty rotas, policies and procedures, quality assurance audits and other records about how the service was managed

Updated 12 April 2016

This was an unannounced inspection which took place on 29 February 2016. We had previously inspected this service in November 2014 when we found it was meeting the regulations.

At this inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because recruitment procedures were not sufficiently robust. You can see what action we have told the provider to take at the back of the full version of the report.

Elizabeth House is registered to provide accommodation for up to 18 older people who require support with personal care. At the time of our inspection there were 18 people living in the home.

Systems for recruitment of staff were not always safe. In three staff files we found full employment history’s had not been recorded. Where gaps in staff previous employment history had been identified there was not a written explanation of the reason, as required by law. This meant people were at risk of being cared for by unsuitable staff.

Staff felt supported and had received the induction, training and support they needed to carry out their roles effectively.

There was a registered manager in place at Elizabeth House. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they felt safe at Elizabeth House. Policies and procedures were in place to safeguard people from abuse and staff had received training in safeguarding adults. Staff were able to tell us how to identify and respond to allegations of abuse. They were also aware of the responsibility to ‘whistle blow’ on colleagues who they thought might be delivering poor practice to people.

People were receiving their medicines as prescribed. We saw there were safe systems in place for managing medicines.

During our inspection we observed that there were sufficient staff to meet people’s needs and requests for support were answered promptly. We found that staff received the induction; training and support they needed to ensure they had the necessary skills and knowledge to carry out their roles effectively.

People’s care records contained sufficiently detailed information to guide staff on that they needed to do to support people. Risks to people’s health and well-being had been identified and plans were in place to reduce or eliminate the risk.

We found the communal areas, toilets and bedrooms were clean and free from offensive odours. Since our last inspection the home had been re-decorated, the kitchen work surfaces had been replaced. New non slip flooring had been fitted in the communal areas and the kitchen. The bedrooms we looked at were spacious and contained lots of personal belongings and photographs. The home was clean and equipment was serviced and maintained appropriately. Procedures were in place for preventing the spread of infection. Systems were in place to deal with emergency’s that could affect the provision of care.

People’s rights and choices were respected. We found the provider was meeting the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). These provider legal safeguards for people who may be unable to make their own decisions.

Systems were in place to ensure people’s nutritional needs were met. People told us they enjoyed the food. The cook and staff had good knowledge of people’s likes and dislikes.

Peoples health needs were assessed and monitored. They had access to a range of health care professionals and any advice was documented and acted upon.

The staff and managers knew people well. They spoke fondly about people who used the service.

People who used the service and their relatives spoke positively about the care and support staff provided. They told us it was homely and people described it as, “Like a family.”

All the people we spoke with were positive about the registered manager, deputy manager and how the service was run. Staff told us they felt supported and enjoyed working for the service.

People told us they enjoyed the activities that were on offer in the home. We saw that events to mark special occasions were organised within the home and that relatives and friends were made to feel welcome.

We found there was a good system of quality assurance. There were a number of weekly and monthly checks and audits. People told us they could raise any issues with the registered manager and deputy manager. The service had a system in place for dealing with complaints and recording any actions taken.

The registered manager was starting to use a new system for gathering people’s views on the service. This showed a commitment to listening to people and involving people in how the service was run and improved.